southern africa, all the way to morocco, you have no protection. at least 10% to 50% of u.s. oil or hydrocarbon are coming from that region. nigeria, guinea, guy "the washington poshost: are y? caller: i am from ghana. in ghana, there was this project where ghana got close to $500 million for a highway. these are some of the things that the u.s. government can do

to help the continent, especially the subregion. a vacuum? does it leave an opening for groups like al qaeda to come in ? guest: there are lots of reasons for american you should. there are limits to what america can do. we are looking at the limits in the face now with the fiscal cliff, which we have delayed a little bit. we have to reckon with it. within that context, we have to look at where our aid can have the most good affect. in mali, our loss to not permit us to deal with governments that come to power through extraconstitutional means. we have the case of the crew -- coup still pulling strings

behind the scenes. it is a matter of military effectiveness. in order to win in northern mali, an outsider will have to engage in a counterinsurgency campaign. taking the people in the north. many have legitimate grievances for political marginalization and discrimination. that allowed the opening for al qaeda and the other islamic extremist to come in. they need a legitimate government to negotiate with. the entity they have there -- no one would negotiate with it because it is not legitimate. it is not supported by the majority of molly ends -- m alians. if you do not have a legitimate government, you are never going to be the insurgents.

thank you for coming in. that is all for "washington journal." senator sanders is talking about primary health and aging.

we have a major crisis regarding primary health care access, which results in lower quality health care for our people and greater expenditures. lower quality health care and we end up because of the crisis and primary health care spending more than we should. today, 57 million people in the united states ban cannot see a . when they need to. lack of access to a primary care provider is a national problem. those who are most impacted our people who are low income, minorities, seniors, and people who live in rural communities.

as we have seen time and time again with dental care, mental health, and other healthcare issues, the groups that need healthcare the most are the least likely to receive it. the good news is 11 months from now we will be providing health insurance to dirty million more americans are the affordable care act. -- dirty million more americans are the affordable care act. we do not know how we will provide primary health care to those americans who will now have health insurance. let me rattle off some statistics that should be of concern to the congress and to all americans. not widely known, approximately 45,000 people every single year die in the united states of america because they do not have

health insurance and they do not get to a dr. in time. 45,000 americans. according to the health resources and service administration, we need 16,000 primary care practitioners to meet the need that exists today with a ratio of one provider to 2000 patients. over 52,000 our merry care physicians will be needed by 2025 -- primary care physicians will be needed by 2025. over half of patient visits are for primary care. only 7% of the nation's medical school graduates now choose a primary care career. 7%. nearly all of the growth in the

number of doctors per capita over the last several decades has been due to a rise in the number of specialists between 1965 and 1992. the primary care physician to population ratio group to only 14%. the specialists population exploded by 120%. the average primary care physician in the united states is 47 years of age. 1/4 are near retirement. in 2012, it took about 45 days for new patients to see a family dr. up from 29 days and 2010. if you can find a family provider, it takes longer than it should to see him or her. only 29% of u.s. primary care practices provide access to care on evenings, weekends, or

holidays. that is compared to 95% of physicians in the united kingdom. our culture is, do not get sick on saturday, sunday. half of american emergency room patients would have gone to a primary care provider if they have been able to get an appointment at the time one was needed. we are wasting billions of dollars because people end up in the emergency room or nonemergent care because they cannot find a primary health care position -- physician. primary care is intended to be and should be the foundation of the u.s. healthcare system. in 2008, americans made almost one billion office visits to the dr..

50% were to primary care doctors. according to patrol -- access to primary health care results in better health outcome, reducing health disparities, and lower spending by reducing emergency room but when you get people to the dr. when they showed, they do not get sicker than they otherwise would be at great cost. the problem we are discussing is a national problem existing in 50 states and the country. it is even worse for particular geographic regions. the ratio of primary care doctors in urban areas is 100 per 100,000 people. double the ratio in rural communities where it is 46 per 100,000. urban communities have problems. rural communities have greater problems.

65% of primary health care a national shortage areas are in rural counties. my own state does better than the rest of the country in terms of primary health care providers per 100,000. i cannot tell you -- and vermont, people have difficulty getting to the primary care provider they need. 20% of americans live in rural areas. 9% of fisher since -- physician's practice there. one of the differences between the u.s. healthcare system and the healthcare systems of other highly developed countries, which could explain why we spend so much more than other countries around the world, is the ratio of primary care physicians to specialists. in the united states, roughly 70% of our practitioners are specialist. 30% are primary health care providers. around the world, that number

is the opposite. about 70% of their practitioners are our merry healthcare providers. 30% are specialist. can congress do to address this issue? -- what can congress do to address this issue? we must address the issue of primary care reimbursement rates. specialists earn as much for their lifetime of practice as 2.8 billion dollars more than primary care providers. if you are going into medicine, if you are a specialist, you can earn almost $3 million and a primary care practitioner. radiologists and gastroenterologists have incomes of more than twice that of family physicians. the system for setting physician reimbursement in this country is determined i the 31 physicians

who sit on the american medical association committee. the payment recommendations are accepted by the centers for medicare and medicaid services. over 90% of the time. they are adopted by many private insurers and is dominated by specialists. specialists sitting on the committee determine reimbursement rates. we have to look at that issue. the care has promoted the growth of residencies and specialty fields -- medicare has promoted the growth of residencies and specialty fields by providing $10 billion to teaching hospitals without requiring any emphasis on training primary care doctors. unlike other nations, which provide significant financial support for medical school education, we do not do this in this country.

the result is the median debt or medical students upon graduation is more than $160,000 and 1/3 of medical school graduates leave school more than $250,000 in debt. what will you do? you will try to figure out how to make as much money as possible to deal with that debt. you will gravitate toward fields that pay higher incomes. if we are going to attract young people into primary health care , we must make that profession more financially attractive. we must address the issue of our reimbursement rates for med. in recent years, we have greatly expanded community health centers around the country. community health centers provide good quality, cost-effective

healthcare. we need to do more than that. we need to make more progress. we need -- we have increased funding for the national health service corps, which says to someone if you graduate circle school and death, we will help you a trust that debt if you practice in underserved areas. it is working. we need to make more progress and that. teaching health centers. residents trained in community health centers or rural communities are more likely than those trained and other treasures more likely to serve n underserved areas. -- in underserved areas. we have to expand that concept. we have to take a look at the role of allied health providers, nurse practitioners, and others. how do we better utilize those people?

we have a very serious problem. the lives of thousands of people depend upon what we do. i am very excited about the panelist we have at the hearing. i would like to hear from .enator and se -- the senator joining you. am back to be i would like to thank the witnesses for taking time out of their schedules to be with us. i would like to welcome toni decklever from cheyenne. i appreciate that you made the trip across the country to be here. it is a pleasure to welcome all of the witnesses to our hearing. the issue of improving access to primary healthcare services is 11 that is important to all of us but is especially significant given the obstacles

people face in wyoming. nearly the entire state is considered a front here or were rural county. 47% of the population is in a county with fewer than six residents per square mile. approximately 200,000 residents live in health professional shortage areas with inadequate access to primary or dental care. there are accesses -- this requires creative solutions. one hospital is served by a physician that every time we lose that position, the hospital closes. the state has developed programs tailored to meet the needs of a frontier state where distance presents the biggest barrier to accessing a doctor. recruiting healthcare professionals to live and work there is an ongoing challenge. the wyoming department of health operates its own loan repayment program along with a

physician recruitment grant program. these programs were to reduce the high cost of health professional graduate and training programs, which is often a deterrent to work in primary care or other lower income medical fields. the wyoming health resources network represent another approach to improving access and reducing primary care workforce shortages. this arrangement between the major medical and health professional societies, the university of wyoming and others maintains an extensive database of wyoming healthcare facilities and their need. sharing information more effectively allows for better allocation of resources and man power -- and man power the fiscal climate limits our ability to spend money on the problem. the criteria that determines eligibility for federal funds to

support rural health programs are based on factors that make it difficult to prove the needs of the underserved. one provider per 3500 people in new york city is different from 3500 people living in fremont. we need to think more creatively about how to use technology services to improve telemedicine capabilities. . the advancement of more powerful wireless technology has potential to remotely link individuals across the country to deliver healthcare and more accessible settings. the have had access with that with some of the veterans outreach clinics where they used telemedicine extensively with nurse practitioners being in charge of handling the equipment and a dr. on the other end. i hope this hearing will make it clear that we need to the

ground ways in which all americans can better access primary care services and ensure healthcare and fresh -- healthcare confessionals are -- healthcare professionals are where they are most needed. i want to thank the witnesses for their participation. i want to thank the chairman for his list of suggestions on things that need to be done. we have the capability to come up with solutions. >> thank you. the senators will get five minutes. senator warren was here first. >> i want to thank you for holding this hearing, mr. chairman. i am very interested in the question about how we equalize access for all of our citizens and how we make the right investments to lower the overall cost of healthcare. the chairman said it best when he said what we are looking for

is better outcomes at lower costs and that is the procuring or role the federal government can make it it makes the right upfront investments. i look forward to hearing from each of the panelist. i want to thank the ranking member. the comments about access and the reminder that it is different in a large city then it is in a rural area are comments that are well taken and one for us to remember. also, they can have different consequences, even in massachusetts where we have very extensive healthcare services in some areas, but it still leaves us with part of the population in massachusetts with difficulties in accessing care. sometimes distance is less the challenge, but cost can be a challenge and transportation.

i appreciate the reminder of the diversity of issues that we face and making sure that all of our citizens have good access. thank you, mr. chairman. >> senator baldwin. >> thank you. i will not use the allotted time in its entirety. i will have to seek out to a tent another committee meeting in return for the q&a. i appreciate your focus on this broad but critical issue that has so much relevance seen through the accreditation of the affordable care act. i represent a state that has urban concentrations as well as not as large spaces of rural areas but has the array of challenges that are the subject of this hearing. i appreciate the attention that

will be focused on it. one of the things that i hope i will hear some collaboration on our side from issues of compensation plays in this is questions of lifestyle for primary care practitioners, things like the differences between the amount of time that somebody might be on call as a specialist versus a primary care physician. as we look at the larger payment reforms, how the flexibility and the practice of being able to spend the adequate time with a patient with multiple chronic conditions that is necessary versus seeing folks and 15- minute increments. what impact will those policy changes have on the number of

primary care practitioners in this country? thank you for focusing attention on this issue. i hope to return to hear more from the witnesses and ask my questions. >> thank you very much. senator franken. >> thank you for this important hearing. we have 13 million more -- 30 billion more americans we hope if medicaid expansion is adopted by the states, leaving some people still uninsured. we read the testimonies last night. it is very clear that when you ensure the people, their healthcare outcomes are better. it costs us money when people are not in short. what we are doing -- it is so

clear. sometimes we hear, we have health care in this country. you can go to the emergency room. that is expensive. it does not mean you get treated after the emergency room and you get what you need to treat a chronic condition. all of your testimonies put a lie to that. i appreciate that. in minnesota, we do healthcare relative to the rest of the nation, extremely well. hhs has rated as number one in high-value care and outcomes divided by cost. we, like wisconsin, at a combination of urban centers and not miles and miles, but we but we have miles

and miles. i look for to partnering on this. i admire the ranking member's work on rural health, which is important in my state because there are people that are underserved. one of the things that the chairman talked about was the student loans. graduating from medical school with a typical loan debt of 160 thousand dollars, sometimes more. -- $160,000, sometimes more. the tendency for doctors to say, how will i make this money? this is an issue you talk about in your testimony. and our country, we pay our country,- ion

we pay specialists more than primary care physicians and we do in other countries that do their healthcare less expensively than we do. one of the things about student loans -- there is nothing good about the high cost of college and graduate school in my mind. except that the only probably good thing is that it creates some tool for us to motivate people to go into the things we need. the one question that i would like the panel to think about -- and i know you will give your testimony and we will do the questions -- is what is the return on investment if we say to doctors graduating critical school -- medical school, will

we do forgiveness for being a primary care physician for a rural area or in underserved rural -- urban area. what would be the return on investment if we really encourage by long forgiveness -- loan forgiveness doctors to go into primary care? what is the calculus there? what is the equation if we say, my goodness, it is such a benefit to society and a cost- benefit to have a higher ratio of provera care physicians -- primary care positions that we said if anyone who goes into primary care medicine, it is $100,000 right there. what is the cost-benefit there? it is good to see you, dr. reinhardt. we have talked a number of times.

he is a health care economist. maybe that is something you can mull over. thank you, mr. chairman, for this unbelievably in port hearing. >> -- important hearing. >> senator murphy. >> i am excited to be here with the fantastic panel. having chaired the health committee and the state legislator and committee -- connecticut, we grappled with this problem. i remember one meeting that i had with maybe 15 or 20 medical students at the university of connecticut. at some point, we talked about the affordable care act and how it could help merkel students. we talked about the issue of high level of indebtedness. i asked, how many of you are considering going into primary care?

one of them raised their hand. we started to examine this question as to why they did not have it on their mind. the dollars for the first thing they mentioned. they would have extreme doubles of indebtedness. they could not figure out how they would make that work with the salary they would make as a primary care physician. as you started to tease a deeper answer out from each one of them, the second thing that came up was prestige. they did not feel there was prestige and being a primary care physician. if you wanted to practice cutting edge medicine, you had to go into the specialties. they had an ego that wanted to put them on the front lines of medicine -- of new medicine. i hope that is part of our hearing. how do we put the practice of medicine back into primary care? how do we allow them to be more than gatekeepers? there is an opportunity as we

roll out these new delivery system models. all test social to practices are the rule rather than the exception. you allow for primary care physicians to once again control a lot more medicine than they used to control. the prestige comes back, maybe not so much in the medicine that they practice but in the control they have over the health care system. as we build a new delivery system, it is an opportunity not to just address how do they make their families'did work, but how do they feel good about the medicine they are practicing and the value they are adding to their profession because that has been lost over the years as the prestige has moved to specialists.

i am magically what examine that topic today. >> senator casey. >> i will submit a statement for the record. i want to thank you for calling this hearing. it is an important issue. the one quick comment i would make is in we go to the attending physician, we have a doctor available to us and the capital. that doctor is our quarterback who can make determinations about our health and can refer us to specialists and others to help us. he hoped that one of the conclusions that results of all this work in this hearing and otherwise is that everyone has a in theirare doctor life who can treat them and get them access to the best care.

th>> senator hagan. >> thank you much. thank you for holding this hearing. this is a critical issue facing our country. in north carolina, we have more than a million people who do not have access to primary health care because of a shortage of providers. i know that when patients can see a primary health care doctor, they end up getting care. when they do not have that access, they go to the hospital. that is where emergency care is expensive. it types up the cost of healthcare. if you have a chronic disease and can manage it, it is less costly. otherwise, they will develop into a acute-care episodes. there are innovations in this area. one of them is in north

carolina, the blue ridge community health services, a community health service in the western part of our state. it received a grant under the teaching health center program. they have served 20,000 patients in the blue ridge through 70,00 0 encounters. they do outreach to the local domestic violence shelter. this funding has allowed them to increase the number of residents at this facility and hendersonville. those residents are critical to helping with providing more primary health care physicians. blue ridge is one of 34 federally qualified health centers in after liner that provide that high-quality, cost- effective care to tuple across our state. there is another provision across the state, and rural physicians pipeline act.

it goods -- it gives resources to recruit students from rural communities. primary care access is lacking and rural communities. if we can train physicians from those communities, they tend to stay and rural communities. -- in rural communities. they have a significant role to play. i am delighted to have this committee hearing. >> senator whitehouse. >> thanks very much for holding this hearing. you have drawn a big crowd because it is an important issue. we are gearing up in washington for a fiscal cliff that will be coming in a couple weeks.

with that looming, we are beginning to hear the refrain about how important it is to cut medicare benefits and to limit access to medicare for seniors and that is the responsible thing to do to save money, which is a preposterous and ill- informed idea, particularly in the context of a healthcare system that is 100 times more expensive than it was in 1960. the graph is an accelerating curve of upward costs. $2.7 trillion annually spent on healthcare that is 50% higher penalty we pay in the united states compared to our industrialized competitors. we are at 18% of gdp. that is $800 billion spent unnecessarily per year. look at the rocketing pace of

the increase. do you think he will solve that by cutting medicare? it is not right. as the ceo of kaiser permanente said, that is an in a way of thinking about healthcare. it is not just wrong, it is so wrong it is almost criminal. herrings like this that point out there is a problem with costs the delivery system in the united states and that we have to trust that problem if we are not going to misdiagnose. on to have a misdiagnosis, you do not get the right sure. it is important that we not throw seniors and medicare under the bus because we have failed to address the real problem in health care, which is in efficiencies and a rocketing cost that are not just in medicare. medicare is the most efficient

deliverer of healthcare in our system. if we get this right, 40% of the savings will come back into federal -- the federal government. the rest will go to blue cross, businesses, and families across the country. we have a fight on our hands to steer this in the right direction. >> i want to remind members of the senate and viewers on c-span that the report that we have done on primary care access is available on sanders.senate. gov. what you have seen today is there is an enormous amount of interest in this issue. we are delighted that you are here. we thank you for the work that you do. let us begin with dr. fitzhugh mullan.

he is the head professor at the george washington school of -- george washington university school of health. thank you for being with us. >> thank you. a great privilege to be here. as a primary care physician and pediatrician who was in the first class of the national health service corps in 1972, it is not only a privilege but a development in history to hear the committee of the senate speak which clarity -- with clarity about the issues of primary care. if i can get over my days, i will be cogent -- daze, i will be cogent. i was supposed to be the expert. you were the expert.

i will focus on the issues of education and system building around primary care. the demand is in front of us. the aging of the population, the advent of the affordable care act, and the entitlement it provides. it presents us with a challenge. we have about 280 physicians per 100,000 in the united states. that puts us in the middle of the developed world. in the uk and canada, they have less. germany and france have more. we have about 800,000 physicians. we have one hundred 90,000 nurse practitioners, physician assistants, and certified nurse midwives. we have a 25% add-on of providers that do not exist 30 or 40 years ago. -- that did not exist 30 or 40

years ago. in the 1960's in 1970's, we were short. the u.s. congress divided programs -- provided programs that live on today. among those were the nurse practitioners and the physician physician -- physician assistant and the health service corps. lean is not necessarily bad in terms of how we function if we want a more efficient system. there are systems that are used to the payments that they currently get. there are not going to change until there is is a real sense of need. we are at that point. i am not for holding where we are at now. we need to think about the advantages that can come from this period. in's of the primary care challenge, i look at it in two ways -- in the factory, the

medical school. the other is in the market. we have had eloquent testimony as to the pay parity gap that exists in simple general terms. a specialist will make twice what a generalist makes. that is a huge problem. while education and training is important, you can do the best education and training and put them out in the market with those intensive --incentives, you will get what we get now. the challenges are both at the medical school level and the residency level. residency is important and influential in the nature of the type of position and location the physician that

comes out of the education pipeline. there is an medical schools a culture that is heavily specially focused. a natural dominance of the more research oriented and subspecialty scientists, which are well represented. the primary care culture is put on the back of the bus. you will not find our medicare physicians who have not been told at some point in their career by a professor, you are too intelligent to go into primary care. that culture is toxic. we need to worry about it. the young dr. today is drawn to lifestyle specialties. this is a problem. with limited hours and refine knowledge requirements and a predictable life, one can understand those draws. we need to work on that. have the sense of social mission. our medical schools have been well treated by the nih that

provides billions of dollars to research. medicare provides $10 billion per year to teaching hospitals or residency programs. with no requirements in terms of workforce product. we put about $300 million into primary care and about 300 million dollars into the national health service corps. $27 billion is generally specially oriented and $620 that is promoting primary care careers. that is a huge imbalance. the teaching health centers are very important innovations. it moves the paradigm into the community. it needs to guarantee a paste rain. -- it needs to guarantee a paste

rain. the nurse practitioner is an important asset. almost 190,000. we need more. they are more noble. they are more easily trained in large numbers. that is a very important feature as we look at scaling up our workforce. data and planning. we have a national healthcare workforce commission. it has not been funded. we need a better bring an hour system. that would be very helpful. we have a moral triumph in the a.c.a. and the entitlement and friends and also a technical challenge. the permits of the thc's. greater funding of the national health service corps will be essential. ringing -- most important is medicare g.e.m.

we need to use that money in a more constructive way. our next witness is tess stack kuenning, the executive director of bi-state primary care association in vermont and new hampshire. thank you for being with us. >> chairman sanders, ranking member, and distinguished members of the subcommittee, my name is tess kuenning. in the executive corrector -- director of bi-state primary care association. i want to thank you for the opportunity to testify on the role of community health care' centers in the role of

addressing our needs. two important events have altered the healthcare financing and delivery systems of our nation. the patient protection and affordable care act and the supreme court decisions. as many as 30 million americans will gain coverage through medicaid or the health insurance exchange. another 30 million will be uninsured. we support these coverage expansions that open the door for a broader health care system. coverage alone does not equate to access. it is access to regular care that makes coverage meaning for ful. our nation needs sustainable solutions to increase our primary care capacity and assure quality outcomes. any efforts to increase access to and sure daschle insurance

must grow and experiment primary care infrastructure. community health enters offer a solution to these challenges. they are located in medically underserved areas and serve everyone regardless of their ability to pay. they are directed by patient majority for its, ensuring karras is locally controlled and responsive to -- hunters are locally controlled and responsive to to ththe communit. the ability to re-care and one 's -- the ability to receive care in one's native language approved -- improved access. i am able to speak nepali with that population.

i see the benefits with this. without access to primary care, many people may delay seeking treatment until they are seriously ill and require hospitalization or care and the emergency room at a higher cost to themselves and the healthcare system. the journal of oral health article found that counties with a community health center had 25% fewer emergency room visits. other data demonstrates that community health centers save approximately $24 billion by keeping patients out of these healthcare settings. congress had the foresight to include mandatory funding to expand the reach of the nation 's community health centers and the affordable care act to ensure the promise of coverage

was met with the reality of care. seeing this plan through is essential. the community health center expansion is not on track. spending only $20 million of the $300 million in new fiscal year funding. the administration has proposed spreading out the growth over a much longer amount of time. we urge that the full affordable care act provided increase for fiscal year 2013 be a merely extended to care for 2.5 million new patients. the demand for community health centers outpaces growth. more than 60 million americans that access to primary care. all of our 19 health-care centers have identified needs.

the core places professionals in shortages -- community health centers are ready, willing, and able to the leaders and reforming our health center. we appreciate your leadership and look forward to your and the committees continued support as we were to provide meaningful health care access to all. >> it is my pleasure to introduce ms. toni decklever, a resident of cheyenne, our biggest city with 66,000 people. we have 200 50,000 -- we have 250 nine towns. we have 14 towns where the population exceeds the elevation. she is familiar with all of those.

she wears several different professional hats. she has visited washington, d.c. bank to advocate for fellow nurses. she is a state director for skills usa to improve the countries were kforce by recruiting people for health occupations. she is a consultant who helps train individuals. she has a bachelors of science degree in nursing. she is a certified emt. she has received awards for outstanding services. we are pleased to have her here today. it took 13 hours for you to get here. >> good morning.

thank you for the community to testify today. the senator stated i represent the wyoming nurses association. i have worked in acute care, long-term care, education, and administration. wyoming is the largest state and the u.s. with almost 100,000 square miles of land. our population is the smallest and the nation with a little over a half a million people. the rural environment impacts our health care systems. 25 beds or less. there are two veterans hospitals and 16 rural health clinics. there are eight community health care centers. three are satellites of larger health-care centers. when dealing with the number of patients and the barriers to care for them, several components need to be considered. the ability for providers to be able to practice to the full scope of their education and i said sure -- licensure.

a short of all five faculty. the quality of care for rural areas. with baby boomers turning 65, there will be an increase in demand for healthcare along with expansion of nonhospital sessiottings. wyoming's nurses practice act allows advanced nurse practitioners to practice independently. disability helps nurses provide patients in rural areas access to primary care. some federal laws and regulations limit the nurses ability to practice at their full scope. a quirk in medicare law has kept our lands from -- r.n.'s from certifying patients. in areas with limited access,

this has led to delays and home health services. this inconveniences patients and their families and can lead to increased cost of the medicare system. this is when patients are left in institutional settings were readmitted after discharge because they do not receive proper homecare. a sufficient supply of nurses is critical in providing our nation population with quality health now and into the future. register nurtures the gas nurses are the -- nurses are the backbone of programs. according to the 2008 national sample, over one million of our nations 3.1 million nurses are over the age of the he with 1/4 of them over the age of 60. the provider population is aging and near retirement age.

studies have identified the retirement of providers is one of the obstacles to providing care. wyoming responded by creating a funding stream that would assist nurses to continue their education and work as faculty at community colleges. this allowed the nursing programs to increase enrollment and educate more registered nurses. they are continue to continue education and to advance practicing. wyoming has a small amount of state incentive, prepayment money. id, some students receive funds from title viii and title vii. many residents are using health services and surrounding states who could have been served and wyoming to address this issue,

we should recharacterize the y tohel -- the situation bu grading services at the point of care, collaborative planning and policy implementation, effective use of financial services, shared responsibility for achieving goals for individual health and organize leadership that keeps the state responsive to changing needs. federal designations provide eligibility for federal to world health clinics. underserved populations are based on factors that make it difficult to prove the needs of the underserved and rural areas. one provider per 3500 people and an urban setting is different than 3500 people living in a county that is almost 10,500 miles of land mass.

wyoming's economy is based on energy production, coal, natural gas, oil, uranium, and wind. the people working in the energy industry make a sufficient salary, but in some cases, it can skew the average income for families based on statewide data. some families do well financially. there are still a number of people struggling to make ends meet. this can be another challenge to meeting designating guidelines. thank you for your time and attention to this important matter. >> thank you for being with us. thank you for your testimony. i went forth witnesse is dr. andrew wilper. he is a practicing general internist. he is the associate program director at the boise internal director program.

thank you for being with us. >> thank you. it is a great honor to testify here today. i was asked by senator sanders about my insight. one about the lack of health insurance in the united states and it affects on health and healthcare outcomes and to share my thinking on solutions to to the primary care workforce shortage. there is an enormous literature that has accrued over decades demonstrating that a lack of health insurance is associated with decreased access to healthcare and worse healthcare outcome. subsequent work has built on this evidence.

a paper we published in 2009 linking lack of insurance to nearly 45,000 deaths among adults in the u.s. annually. the research is consistent. health insurance leads to significant is tbenefiterss. in an health insurance does not guarantee access to -- at the national level is to bolster our primary care workforce. there is an additional massive body of literature supporting the idea that a primary care improves all sorts of health outcomes and lower costs. he had not seen changes to eliminate the shortage of pcp's in decades.

talk about three policy levers that this committee could consider to increase the number of physicians entering into the primary care workforce, some of which have been referred to. at the medical school level, this is the time after which people graduate from college and are in their undergraduate medical training. >> in addition we could direct support to community health care -- to community health centers. second point would be the area of graduate medical education. specifically to go toward primary care programs, these are continuously under threat of congressional cuts. they have been cut dramatically in the past 10 years. if we emphasizing that funding would be an importance that. -- re-emphasizing that funding would be an important step.

as we have heard today, nearly $10 billion is spent by the federal government to support these hospitals. currently we do not have any plan in place to meet the needs of our population in the united states with regard to work force. medicare should also require the regional community work force to provide for this funding. graduates select their fields of practice based on their personal interests, to emphasize the point made a few minutes ago. i have been told that his concern -- perhaps the most important policy reform that we can make to reinvigorate primary care is to address the pay disparity between primary-care physician specialists. this can be done by raising pay

or decreasing that of specialists. i think it is the disparity that is the driving force in this workforce problem we are facing. the american association of medical colleges has declared that training cannot overcome market incentives. a focal point for payment has been mentioned in the subcommittee of the american medical association. this is a secretive group of doctors that wields tremendous influence over medicare reimbursement rates. cms adopt all of their recommendations. we should establish a process that does not encumbered by great interest or favored by specialties. in summary, it is eminently

clear that health insurance -- despite its current format to do so. in closing i have worked for over a decade in medical education assistance, resident, fellow, and now a faculty member. it is my conviction that publicly sponsored training should be planned to meet the needs of our population, rather than the staffing needs of hospitals or the lifestyle preferences of young doctors. >> thank you very much. my understanding is that is next.rankefranken >> that would be a yes. you are talking about compensation. as you probably heard my comment earlier about the return on investment in terms of loan

forgiveness for primary-care physicians. what would that look like? in other words, i know we do some loan forgiveness for people serving in underserved communities. what would that look like? and how could you compute that in terms of the value you would get back over the course of the position's career -- the physician's career. has that been looked at? >> thank you for the question. to my knowledge there is no systematic review of that

specific question. i know in idaho we have programs in place to help offset educational debt related to medical education. i would refer to my panelists to my left, dr. reinhardt. >> may i ask that dr. reinhardt? if you have more primary-care physicians -- if you have more primary-care physicians we can convert that into quality adjusted life. usually the assumption is that he was and is imputed to that. -- value is imputed to that.

by having more physicians in that field, how much better quality of life have you produced? i would suspect return is fairly high. -- i would suspect the return is fairly high. >> i have two minutes left. i would like those three seconds back. to senator murphy's comment about the status -- i think your status as partly determined by your salary.

i do think the relative value board you're talking about -- you were talking about -- in other countries, what is the compensation in terms of general practitioner to specialists? is it different? is it lowered? is the ratio hire from gp to specialist in other countries vs here? -- is the ratio higher from gp to specialist in other countries v. here? >> not as much as here. they generally do have lower pay but i do not think the ratio is quite as large. >> and have lower health-care costs and as good as outcomes if not better, right? >> about half.

>> senator murphy again brought this up, -- what they elevate the role of a general practitioner in the sense that they would be organizing this team the does the care? unlessh regard to aco's, payment mechanisms are changed -- and there is a proposal to do that in these medical home models -- there is a chance that would move the needle in terms of primary-care physicians reimbursement. there is very limited evidence

that patients center medical homes are going to reduce costs. i think that intervention, why were the to work on at the state -- while worthy to work on at the state level, it is still experimental. >> i just want to ask one thing -- i think it was off base to have the ranking member to have you come here to testify about his weekly commute. [laughter] >> let me introduce a man who has already spoken -- dr. uwe reinhardt. he is the former prof. of economic affairs at princeton university.

dr. reinhardt, thank you very much for being with us. >> thank you. i am very honored by it. i should have added that i was delivered by a midwife and my mother once told a member of the medical association that it shows. i/written statement into three parts. one is our current work force sufficiently use. the second is what public policy leverage does the congress have given we want more primary-care physicians to move them into that field and all to the

practice where needed? and the third question is to what extent can financials be used? the traditional model of workforce forecasting has been focused on physician population ratios, as if other people in the primary care team does not matter. my whole career has been to say we should not use physician workers far more imaginatively and let them practice independently and focus -- and have full controvert -- and have full competition with other positions. that was very controversial. the congress has played a large role in innovating in this field. the training of nurse practitioners and assistance,

also creating community health centers in other settings where they can be used very effectively. usually licensing is excused -- professional licensing -- with an appeal to patients' safety and quality i think it is mainly over economic turf. i remember the fight over whether optometrists can dilate pupils. those were the issues. it was almost like an insurgent wars that have to be fought. i believe congress should simply make sure that licensing is driven by clinical and economic considerations and not by economic terms.

there are the scopes of practices. i believe there should be an agreement with the nursing profession. there should be a standard sop for the nation, which shoudl allow nurses to practice independently. physician assistants by their nature are supervised by physicians. on the second question about how you can drive physicians to the extent that you definitely need them in these teams into a primary care? it is an issue of prestige. senator murphy mentioned that. the models of primary-care, the medical home, the acos, etc., will enhance the natural power. it is not just money, it is power. they are no more or less traffic

cops. i tell that to our daughter who is an intern. she said, "i would be very excited to be a primary care physician." the audit and a real opportunities are limitless there. -- the of entrepreneurial opportunities are limitless there. conversation is clearly an issue. you mentioned over a lifetime of specialist gets to three -- its two million dollars to $3 million more -- a specialist gets two million dollars to $3 million more. i think first -- i think

forgiveness should be done. i would say for every year you practice -- if you go into a specialized primary care, i would say $80,000 up front and every year you specialize in the location we would like to go we will forgive you $20,000 to have that incentive out there. finally, when allowing private equity managers to pay spurned income commissions and get capital gains tax since -- i said, why don't we honor primary physician says in america and give them the same rate if they go to rural areas.

congress as we want to encourage capital formation. that is capital. physicians are human capital. we want to encourage them. thank you mr. chairman. >> last, but not least, is dr. claudia fegan. she is the chief medical officer of the john h. stroger jr. hospital of cook county. she was interim chief medical officer of the cook county medical services. she received her undergraduate degree and her medical degree from the college of medicine. thank you so much for being with us. >> thank you.

as a chief medical officer, i confront, on a daily basis, our country's failure to provide universal access to health care and the right to which i believe everyone is entitled. every single day people without a position line up from -- line up across the street from our hospital. hundreds of people a week, tens of thousands a year. the standout in the wee hours of the morning, hoping to be the 120 to 200 people we will be seeing that day, even better hoping to be one of the 12 patients assigned to a primary- care physician and given appointments. they hope to be one of the lucky ones to get position of their very own. our current influenza epidemic highlights the vulnerabilities of our current world for health care delivery.

too few people have access to a primary-care provider. a primary-care provider could educate them about the influence of vaccines, especially in vulnerable populations. then their primary care provider could have given them that vaccine. at the peak, our emergency room with seating four hundred and 50 people a day. were seeing a four people hundred 50 people a day. we never close our doors. we created our system to compensate physicians in their cognitive effort to care for the patients. we would hope that began to level the playing field for primary care specialists. yet these rvs update commuittee

only has a few seats allocated for primary care when sending reimbursement rates. we want to increase the number of primary care physicians that when medicare fund and grand education funds from hospitals -- if we increase hospital reimbursement for training, we will have more primary-care physicians. you could do that. i have to say i have the privilege of being a primary care physician myself. i love taking care of patients. it is one of the most fun things i do. my patience invite me to their lives as i teach them how to take care of themselves and give them what they need. the daughter of a labor union organizer and social worker, i could never have been able to afford medical school. i was fortunate enough to be a member of the national health service corps. i was free to make a decision to follow my passion and become a friend -- and become a primary

care physician without worrying how to pay off my loans. if i would say to you, if medical students know before they begin medical school they will have no debt upon completion of their studies, if they will most likely make the decision to pursue primary-care rather than a highly complicated it specialty. this is an administrative burden would have placed on our physicians. each insurance plan is with its own set of rules. it is enough to drive me to distraction or exit from our profession. if we enacted a single payer health care program where everyone was entitled to health care, we could focus on delivery -- on delivering the best care to our patience. the stress is on primary -- the stresses of primary-care physicians is tremendous.

with the implementation of health care records that force them to spend more time looking at the computer than their patients. most systems were designed to enhance physician billing, and outpatient care. it robs precious time from the physician they would rather spend on their patients. there is no question that we designed it -- if we had designed it for clinical care we would have developed a very different tool. it is far overshadowed by the administrative demands for documentation. we lose the narrative of individual patients who use the point and click documentations and make billing more efficient. the patient's need elected officials who care about them. >> thank you very much. let me begin the questioning.

i want to ask two brief questions. my understanding is that if i have the flu or a non emergent type of illness it will cost medicaid something like 10 times more than walking into a community health center to visit my primary care physician. my understanding is there are millions of americans who hesitate -- people get sick, they do not go to the doctor, they wait for months. my question is how much money and human suffering is taking place in this country because people are unable to walk into a doctor's office when they need to? who wants to respond to that? >> i can tell you about the

faces of the patients who live to be seen in our walk-in clinic on a daily basis. i do not know how you measure the cost of human suffering. people come to us because you can see things you will never see anywhere else in the world. such advanced stages of diseases from everything like brain tumors to lesions that are eroding from the skin. i am going to tell you, these people are working folks. these people are taxi drivers, college professors, accountants, attorneys, and the first thing they say to me is they never thought they would be at the county hospital. in no exaggeration, it has to the millions of dollars we lose in work-force productivity as well as the suffering -- i see so many patients who get cancer

and lose their jobs and wind up coming to us to get for their treatment. they lost their homes. we are trying to figure out how to get them started on their chemotherapy while they find a place to live. >> i know from the stories from the community health centers in vermont, i cannot put a dollar a question to it, we have so many stories. we had a farm worker program that goes out to the farms. we have a 50-year-old farmer who has a history in his family of diabetes. he comes in and does not know that they can get care at a community health care. a lot of it is out of reach and enrollment into understanding both the cultural issues as well as being able to get them into care. >> let me switch gears and touch upon another very important

issue in terms of how we determine reimbursement rates for physicians. that is the rock, which is not a household word through america, an organization that plays an important role in determining how specialists -- how much primary-care physicians will make. we have an organization that is top heavy with people in specialties. is this an important issue? >> when we talk globally about the idea of inequity, how do we get a handle on it? medicare is the largest single care and historically many cares key off medicare, managing the conundrum around the pay gap would be central to reforming the whole system.

it is well wired in the sense that it has been this way for a long time. there are a variety of approaches to it. you have lurking under it the question of do you raise the floor or bring the ceiling down? both will raise issues for all people involved. i believe it is both. the point is we are not going to be able to pay our primary care physicians $5,000 per year. when i hear a position makes $500 million -- $500 -- $500,000 to a million dollars per year -- >> i have some additional thoughts on this, specifically the process by which they rock

evaluates building codes between the different sub-specialties and primary-care is. an example of this is as follows -- and ophthalmologists will build the same for code -- will build the same without a follow- up needed. now the reimbursement for those two services are identical. what we need is a new code for primary care. we need to update our knowledge base regarding this issue. as current time estimates for these codes are outdated, 25 years old, a proposal would be

to develop an independent process for reviewing these codes that as transparent and based on real-world data. >> dr. reinhardt, briefly. >> it determines relative values, not absolute levels. it is a zero sum game. medpac proposed there be an outside committee of stakeholders that audit and review the recommendations. i do not know if that ever went anywhere but i would encourage you to look at that and maybe go that way. >> thank you very much. senator enzi? >> thank you, mr. chairman. i will begin by asking mr.

decklever -- what needs to be done and the federal level to improve the grant process and what can we do to make the process better? >> the information i received from the community health centers refers back to -- when they are looking at designations. it is the number of people per provider rather than the amount of space where those people are located in. the other thing that is sometimes a bit of a disparity is in states like ours where we have lower minority populations , sometimes those designations were put out of the running because we do not have a high

enough percentage of minority or different types of ethnic backgrounds. and, again, the wage disparity. the average statewide data designates that the areas are -- if you look at where people are making a lot of money and some that are making very little, it skews the average. maybe look at those types -- as thepe of data as far information goes. >> what needs to be done to enhance the collaboration and coordination between the state and federal government agencies to most effectively deploy the resources? how can we avoid duplicate efforts?

>> i know that in terms of accepting a loan repayment dollar, there are restrictions on how you use those resources. it has to be within health professional shortage areas. if we can get a change from that in federal government, states like vermont or new hampshire that to not take funding for a long repayment, that actually would be very favorable. >> thank you. >> i do not have enough information to give you but i would be happy to do some research on that and get back to you. >> i do have some other questions for everyone on the panel.

a question for dr. mullan, what needs to be done to ensure the effective oversight and financial controls are in place to ensure that federal funding is being used effectively and helps professional resources to be allocated more efficiently? >> the array of federal programs are quite different. i have spoken to the issue of medicare gme, which you would not issue a contract without a deliverable -- without specificity. i think oversight there is quite last. i realize that is not the jurisdiction of this community. -- of this committee.

i. x-ray managed to use of nh type award systems. i think there is good supervision with perspective schools. it is very hard to move when things are highly stipulated. the national service corps has a relationship with the individuals. there used to be many individuals who bought out and did not serve. that has been tightened with federal legislation. there is at attendees if you did not serve your full scholarship. i think this area in general is good with accountability across the programs. no doubt there is room for improvement. >> my time is expired. i do have some more written questions. thank you. >> senator warren?

>> likes amateur enzi, i would like -- like senator enzi, i would like to talk about the access to costs and disparities. i read through all of the testimony and i was very impressed by the work you have done. it has been terrific work. i was very glad to hear about the work that has been done out in wyoming. what i would like to know is what else do you know about any of those dimensions, cost, access, reducing disparity? can anybody speak -- your head popped up. >> in addition to my work at the va, i also worked at the

community health center in boise, idaho. it provides a critical safety net for the uninsured of our valley. the an insurance rate for this population is nearly 50%, which is the second-highest in the nation. my experience in that clinic is that despite the access that it provides, oftentimes there are -- what we end up providing is care we would not find acceptable because it did not have the resources. even though they have a foot in the door to the clinic at the community health center come off the time patients are unable to access additional services that would be standard of care in other system of the u.s.. >> [indiscernible]

>> is your microphone on? >> i thought it was. what we find is we provide access to primary care -- we cover specialty needs. one of the big problems we have as a hospital, one of our major challenges is that these patients do not have anywhere to go for the services and they are referred to us. i think community health centers are valuable because they offer care in the community where people live -- people who do not normally have access will have access. but then they do not have anywhere to send them. we are the safety net. it is a continuous attention we have with capacity. >> did you want to add? >> i had the privilege of

working for 12 years at a community health center about 3 miles from here. what i saw there was a population that were it not for the health center would be in the emergency room. there are not private providers. they were not prepared to deal with the folks clinical needs, language needs, the support needs of this population. those around d.c. have hard wired in social work and mental health a variety of services to provide kinds of needs that our population had. it represents a one-stop shop, which is in the spirit of primary care. without that, the emergency room would be every course -- would

be a re-course. >> i would characterize what we are doing in vermont -- we are working towards redesigning the finance and delivery system. community health centers are a part of that. there were three acts that came out of the state house. they were all primary-care- centric. you are also going to change with regard to the delivery service in terms of acos. you are not aligning in terms of your governance but you are aligning in terms of the total medical s bands. -- medical expense. we are not doing it based on the volume of care, we are doing it based on value. that whole system is being done

at many community health centers across the nation. the valley is a great example. it is a great example of how they be designed the business to actually have providers bring in more assistance to the health centers, and they saved over $1 million at just one community health center. that requires having electronic medical records so you can actually see where your patience go. -- your patients go. this whole concept of aco, as long as it is primary-care centric, aligns the thinking of both financing and delivery for our patients so that we are thinking about total medical expense.

>> thank you. it is estimated we have a $24 billion savings from the current community health centers. part of it is coming from keeping people out of the emergency rooms. part of it is coming out of integrated care. as dr. reinhardt talks about, different kinds of providers. it is also coming from these innovative approaches. >> a lot of the patient center medical homework in vermont, we have a concept called a blueprint. it is thinking about chronic care management. how do you take somebody who has a higher prevalence of diabetes are met -- or as much and how you manage their care to keep them out of the emergency room? it is about focusing in on the patient rather than the delivery system. >> thank you very much. >> thank you senator warren.

senator baldwin? >> thank you for the focus of this hearing. the title speaks volumes. 30 million patience and 11 months ago. -- patients and 11 months to go. our states have different experiences as we move towards those challenges. i apologize earlier for having to step out to another organizational meeting. i missed some of your testimony. i would like to hear more about your opinions and your level of knowledge on the impact of the

non innumerate of factors in keep it -- in increasing the supply of primary-care practitioners. medical students are going through their rotations and observing the specialties as well as joining primary care settings. they are observing mentors and teachers with different levels of autonomy, different levels of flexibility. i think about the difference in experience one might have if they are in a setting where they are modeling a patient center medical home versus other settings that would be seen as more traditional. how much is their mentor and

teacher on call? i am wondering about the level of knowledge how these non- compensatory factors play into making -- in making the decision to go to specialize or primary care practices. i understand you did raise that point briefly in your testimony. i was wondering if you would start. >> thank you. we could spend the afternoon on it. >> i would love to. >> i will be very quick. the cultures of medical schools and teaching hospitals have developed as a very reductionist research oriented culture. all of our medical stook -- all of our medical schools have that element. some do better in terms of local focus. i would like to see every

medical school have a workforce plan. i often travel to medical schools and ask what their geography is. state schools -- a very new model of changing the culture is an osteopathic medical school in phoenix. they have one year on campus for the basic sciences. they take classis for the last three years and distribute them to one of 11 community health centers. they do all of their teaching in a community health center working with regional hospitals. that is breaking the mold. when school is doing that. there are other experiments. we have to 10 of our leading universities that do not have family practice departments. they say that it's someone else's problem. these issues are court to the

economy of this country, the health of this country, and the nature of the physicians that we produce. i think general medical schools that have not taken this challenge -- there is a great amount of work to be done. that is just an example of the possibilities. >> i am particularly interested in knowing how much do we know about this rather than the anecdotal sharing we here? >> in 2009 a foundation published a comprehensive report on this issue and lifted these non-financial factors. one of them is the background of the students. people from rural areas are more likely to go there.

through the admissions process you could probably rearrange the classes. part of it is the culture. i have also read, as one of the senators said, you are too smart, you should not go into primary care. one way to perhaps do this is to graduate medical education and support. a lot of experts do not believe it is warranted. you could differentiate and give a teaching hospital more if they develop programs that specifically account students into this so that the residency is in a community center and they have first-rate faculty who

do mentor them. medical schools react very much like everyone else to the money. i think we just threw the direct medical education at them without asking much in return. >> thank you. senator murphy? >> thank you very much, mr. chairman. i worry about our ability to micromanage this problem. a lot of the ideas we are talking about are incredibly important. but whether it is great setting or loan forgiveness programs -- i am sometimes more attractive to the idea of resetting the marketplace itself to give the marketplace more reason to invest in primary care. one of the things we talked about is how this delivery

system based on a bigger systems of care, that it may lend -- it may help solve this prestige issue. if you are in charge of specialists as opposed to referring out to specialists, you feel better about your work. there is a theory that says if you have more primary-care doctors working for organizations rather than working on their own and you have an aco that is getting a payment to take care of a big group of patients, the aco is going to be incentivize to pay its primary care physicians more. that will help keep the delta of whatever they say. you already see that happening. more primary-care physicians are going to work for hospitals, more hospitals are starting to

buy out primary care groups. i pose that as the question. is there a potential that as you ship the delivery system to have more integration -- more integrated systems of care and more accountable care organizations that there will be an incentive for the organizations to pay primary- care doctors more separate from the decisions we make on reimbursement. i will put this to the economist first. dr. reinhardt, what do you think the shift in delivery system would mean for the rights primary-care doctors get paid? >> the great hope is it would do exactly that. a bundle payments would ideally have capitation for chronic care or bundled payment for episodic care. somebody should be in charge of

managing that money from that bundle. we realize that in the component of primary car rid of primary care is cost minimizing. i once talked to a group in the north texas medical group, they were an integrated ip a. -- and into ipa who took rissk. ks. they told me they had paid specialists less because they were at risk for capitation. they are now an aco. they were one of the pie a nearcos. -- pioneer acos.

>> you expressed skepticism towards the literature. what do we know about the ability for acos with primary care specialists elevated to get cost savings that we have not seen in earlier rollouts of medical home models. >> to my knowledge we know very little about how acos will reduce costs or what their effect will be. what we can look to is the model of care -- we have people who returned from service and to a very good job of taking care of them. we provide care that is of similar or better quality to most private institutions in the united states very much lower costs. >> one final question you had a

provocative statement at the end of your testimony about the interests the ama may be serving here. can you elaborate? >> i would be happy to. my personal position is that this subcommittee of ama wheels inordinate power over rates. i know we are trying to get away from enumeration. i know the federal government has a very clear pricing about what the what the students to practice. to minimize that is dangerous. my personal view is that physician groups treat public appears as though they were their own entitlement programs. >> thank you. senator casey? >> i have two questions. one would be more specific and the other is more broadbased for

the whole panel. we appreciate your testimony here today. the specific question -- i will -- it it to a doctormulldr. mun relates to children. we have to treat children differently and have strategies that recognize that reality. there was a debate where senator dodd and i worked together to design elements in the bill that would speak to that reality. we had one in particular that spoke to the work force.

health care work force loan repayment programs, establishing loan repayment programs for pediatrics and specialists and providers of mental and behavioral services to children and adults who would be working in health professional shortage areas. it goes on from there. that was our intent. we -- i do not know if we were successful. moving beyond this to the theoretical stage, there is a piece of legislation that is continuing to be implemented in this broader topic of primary- care. are the steps we need to take to make sure that primary-care physicians and the services and treatments come with it are available for children? >> your observations about children are on point. children are more vulnerable.

they are more underserved than the rest of the population as a matter of analysis. we are weighted towards the elderly in terms of public benefits. that creates a challenge, particularly with theaca principles. i believe we are more optimistic, especially with the medicaid expansion, kids will get better benefits than they have in the past. the specific issues in pediatrics -- generally the notion of primary care does not include sub-specialty. i think the more correct notion is underserved or underpopulated disciplines, which primary-care is the heart of it -- we have a growing trend of shortage. pediatrics sub-specialties, i do not know the area. there is not the tendency of

pediatricians to sub- specialized. we probably do need more. the spirit of the legislation was encouraging that makes sense. i want to see the profile well over two-thirds of adults going into hospital medicine. there is that challenge. pediatrics has had a good market. medical students like it. they go into it in good numbers. pediatrics is not short. some specialties are. >> from the vantage point of chicago and the pediatric work force? >> the issue of pediatrics specialist is because pediatrics tend to be a lost leader for hospitals. the number of specialists that are pediatric specialists that are available at general

hospitals is very low. in chicago we actually have a glut of pieta hospitals -- of pediatric hospitals. i know in rural communities this is a tremendous challenge in terms of providing access to those complicated children who need multi-disciplined support. providing the services for them is increasingly difficult today. encouraging people to not only -- it is not all that the specialties are underrepresented but they are poorly distributed. >> anybody in the middle? do you want to comment on this question or not? i will put a question on the record. >> thank you. let me conclude by thanking all of the senators who participated in this. i think the large turnout tells

you how seriously many of us feel about this issue. most importantly i want to thank all of our panelists for their wonderful testimonies. we have listened very seriously to what you have to tell us. i especially want to thank those who came from such far distances. thank you all very much for your help. this hearing is adjourned. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013]

>> if you missed any of this hearing, you can find it shortly in our video library at c- span.org. a look now at president obama leaving the white house this morning, heading to las vegas where he will outline his plans on immigration reform. the white house says the purpose of this trip is to redouble the administration's efforts to work with congress on immigration. yesterday, a bipartisan group of

senators released their proposals on emigration. we'll show you that in a minute and we will have the president's remarks live here at 2:55 p.m. also boosted that railhead is stepping down. the only republican whip in the cabinet says he contends to remain at the department tell his successor is confirmed. up next, we will show you some of the remarks yet -- from yesterday's afternoon when bipartisan group of senators outlined their plan on immigration. here is what they had to say. >> we announced today that the five of us here today and eight of us in total, including senators mccain and durban have come together on a set of bipartisan principles for comprehensive immigration reform legislation we hope can pass the senate in overwhelming and

bipartisan fashion. we still have a long way to go, but this bipartisan group -- sorry, we still have a long way to go, but this bipartisan blueprint is a major breakthrough. it is our hope that these principles can be turned into legislation by march and have a marked up by chairman leahy's committee with passage by late spring or summer. senator durban and i spoke to the president yesterday to update him on the group's progress. he could not be more pleased. he strongly supports this effort. the key to our compromises to recognize americans overwhelmingly oppose illegal immigration and support legal immigration. our framework contains four basic pillars. first, we create a tough but fair path to citizenship for

immigrants currently living in the united states contingent upon securing our borders. second, we reform our legal immigration system to better recognize the characteristics that will help build the american economy and strengthen american families. third, we create an effective employment verification system that will prevent identity theft and and the hiring of future of our authorized workers. lastly, we establish an improved process for admitting future workers to serving the future workforce needs while simultaneously protecting all workers. other bipartisan groups of senators have stood in the same spot before, trumping similar proposals. but we believe this will be the year congress finally gets it done. the politics on this issue have been turned upside down. for the first time ever, there

is political risk -- more political risk in the opposing reform. we believe we will have opportunity to act but only if the effort is bipartisan. by their presence today, my republican colleagues are making a significant statement about the need to fix our broken immigration system. we democrats are equally serious. we do not want immigration as a wedge issue. much rather, we want a bipartisan bill let solve the problem and becomes law. we recognize that in order to pass bipartisan legislation, all this can get everything we want. that's why our for marks as we can address the status of people living here illegally while at the same time supporting our borders and creating a system that ensures we will not again confront another 11 million people coming in here illegally.

on day one of our bill, the people here without status who are not criminal would be able to live and work here easily, making it easier to learning. -- to learn english without fear of deportation. but to prove to the american people we are serious about permanently ending a legal immigration, we say we will never put these individuals on a path to citizenship until we a fully secure our borders and combated the pattern of people overstaying their legal emigration visas. we are asking our colleagues in the senate and house to join this in this difficult work. it is time to work together to pass legislation that improves our security, grows our economy, and insurers we will continue to be a nation that lived up to the values of our founders. >> we will have president obama's remarks on immigration

policy this afternoon. we'll have live coverage at 2:55 on c-span. george washington university hosting a panel discussion with current and former members of congress who will participate in a box economic crisis, demonstrating by partisanship and economic prepared this. the director of the gw school will moderate the discussion. that's live at 7:00 on c-span. the u.s. house is coming in for a pro forma session only for about 55 -- in about 55 minutes. the freshman class president was our guest this morning on "washington journal." a republican from indiana, president. why have you run for office? what do you hope to accomplish? guest: i was a staff person out

here, 15 years ago. i have been back in indiana over the last decade with my family. like most americans, i feel like they are spending too much money in washington. i was part of the leadership team in indiana, which has been led by mitch daniels over the last few years. we have been operating with a much leaner government. i think some of those lessons could be applied to washington. host: some governors are calling for change in the republican party. how do you bring about that change? is it tough, having spent time in washington already? guest: most leaders in the republican party do not believe that we need to change our principles, lower taxes, economic opportunity -- those

have worked for several years. what might need to change is how we talk about those opportunities. it is math and we need to do our arithmetic correctly. for a government that does not waste dollars and put money back in the pockets of everyday americans, with better opportunities to retire with prosperity. there is some wisdom there in the fact that we need to think about the way we market our ideas. host: how has this year's republican class freshman group been different from the one that came in in 2010? what is the overriding characteristic of your group? guest: in terms of where we are similar, it is a very conservative group that wants to see very lower taxes and less government. i have not spoken to a single member who believe they came

here with a mandate to raise taxes. but i think there are ways where we are different. this is a group of people that came here not just to be something, but to do something. people with a pragmatic view on balance checkbooks and private business. we have many members of the military out there who have fought wars and who in the real world you have to get along, even if you disagree. it is not that we are less conservative, but we might be able less fire breathing. host: how did you become class president? guest of the campaign for that began just a few days after the election. we started picking those within a few weeks. we have 35 members in the class. in the end it was not a contested election, i was able

to run out in front and do it by acclamation. host: let's take a listen to comments made recently by john boehner, who was speaking before a conservative group. here is his conversation about the dynamic of president obama and the gop. [video clip] >> it is pretty clear that the president knows he cannot do any of that as long as the house is controlled by republicans. over the next 22 months we intend that to be the focus of the administration, as they attempt to annihilate the republican party. let me say that i believe that that is their goal, to shove us into the dustbin of history.

host code you agree with the speaker, that the president wants to annihilate the gop? guest: when you look at the speeches, the state of the state, state of the union -- sorry, the inaugural speech, that is usually a time viewed as bringing people together, the better angels of our nature. frankly, i think that his speech was pretty partisan. a combination of what was left of a campaign speech and the beginning of a state of the union speech. it is clear that they would like to see a democrat- controlled congress. as conservatives in charge of the house and people responsible for governing, the american people expect us to do our jobs as well. we have done that some. i think you will see it even more in the debate comes up over the next month. continuing resolutions,

sequesters, and i think you will see conservatives' standing strong to make sure that our view is part of this coalition. host: how did you vote on the debt ceiling issue? guest: i did vote for the no budget, no pay bill. i believe it is an important principle. i just left this weekend, handing copies out in the district. people think that we have to stop spending money that we do not have. as i mentioned, budgets are not the sexiest topic. it is difficult to get 1 million people to march on the capital because we do not have a budget, but what families, small- business owners, church leaders, school board members understand is that if you do not have a budget, you spend more. it is remarkable what has, on. in some ways the bill was a gimmick, but within a few hours patty murray held a press

conference announcing that we would pass a budget this year. i think that that is vital in bringing together some sort of compromise over the course of the next several months. it is difficult to have legitimate policy discussions without numbers to look at. host: congressman luke messer, from the sixth district of indiana. woodbridge, virginia, democratic line. hello. caller: i want to address people who say they are conservative in the congress, but then do 20 or 30 abortion bills. they start a program like homeland security in 2000, going from zero to over 800,000 federal employees. they call themselves conservatives and are not cutting anything.

we started two wars. that is huge. i have a whole bunch of other things, but i am kind of nervous. host: you give us a lot of things and in your call. your response? guest: the caller identifies with the frustration eupepsia -- all across this country. it has been touted that the approval rating of congress has been around 12%. some of that is earned, but it's continue to grow. you are about to see over the next four, six, eight weeks the policy dynamics of the sequester, it will happen unless something changes, paul ryan, speaker boehner and others, they expect a sequester to hold.

for the first time in a long time on something the government will be spending less money on something this year. host: republican caller, go ahead. guest: thank you -- caller: thank you for taking my call. congratulations on your appointment as freshman president. my comment is that i am hoping that our freshmen republicans are going to toe the line and stop the rhetoric and get on message to cope with spending, decreasing our federal budget. talking about the debt limit coming up, i hope they have the wisdom and the strength. i do not believe the message we're sending out there is appropriate on the debt limit. what is annoying to me is that when they say the credit ratings dropped because of the

partisanship in washington, it is because of the budget. i wish you luck. thank you. guest: i think that the caller makes an important point. it is the cloud before the storm. over the next month you will see a very important point on the sequester and the resolution. the caller made the point that our messaging needs to get better. from my perspective, that is us talking about the why. i have an 85-year-old grandmother that celebrated her birthday this past week, has worked her entire life and she cannot survive without social security and medicare. we need to protect those programs.

i have a 63-year-old mother nearing retirement who has worked in a factory her entire life. we need to protect social security and medicare for those nearing retirement. the president talked about this metaphorical four-year-old girl that is waking up in america and wants the opportunity to succeed. i lived that life. i was raised by a single mother. we lived in a factory town in indiana and i have lived this opportunity for the american dream and we want to make sure the next generation has the same opportunity but that will only happen if we quit spending money that we do not have. if we continue to pass this debt onto future generations, we risk an america that is different than the one we grew up on. it does not have to be, in the next couple of months will be the debate that gets that done. host: let's hear from john in

indianapolis on our independent line here at -- independent line. caller: hi. i was wondering if you were going to do something for the people in indiana. the fact that we pay welfare to a billionaire so his team of millionaires can have money, and do not commit the rhetoric about jobs. guest: the caller makes an important point. we need a growing economy. the best way to balance the budget is a growth rate of three percent-five percent, and the way to do that is tax reform, most people in indiana are not interested in congress bringing the bacon home, but people voting for the policies that will grow our economy and

get us to better paying jobs. one of the things the caller points out and it is very important, for many workers the wage scale is going down. host: the last caller was from indianapolis. tell us about your district. guest: it is 19 counties. it stretches from winchester and muncie, then in the center part of the district it is in greenville, shelbyville, and then madison on the river. it is a district of manufacturing and agricultural communities, what i call courthouse towns -- and it is also where i grew up. i grew up in greensburg,

indiana, played high school sports in many of those counties, and i have been raising my family in shelbyville, indiana, with our daughters and our young son. host: a comment of -- on twitter -- what surprised you the most since becoming a new person in congress? guest: really the pace. 15 years ago i was a press secretary for ed bryant and walked him into the studio and was starstruck, but even as a staff person i had no idea how busy these people are. i think at times it makes it difficult to process policy. the entire going so quickly. the second is one cash, but as a state legislator, we have something called a quorum, which means if you are debating you can call a quorum and force

members to listen to you so that business can continue. in congress, there is no quorum. at times if you tuned in and it seems like nobody is there, it is because nobody is there. i think it makes it challenging in processing public policy. i understand in part why it is not that way. people are busy. the third thing, maybe, the very first day i was there we voted on a portion of the sandy relief aid, the $9 billion related to the insurance program. that was almost all of indiana's first-year budget, and that that was my first day of work. the size of the money is remarkable. host: kirsten luke messer, worked for ed bryant, and was legal counsel for huntsman jimmy duncan. he also worked for -- congressman jimmy duncan.

he also worked as a counsel on regulatory affairs. in indiana, he has served in the state house of representatives and is the executive director and chief spokesman of the indiana republican party. he cofounded a nonprofit called child share indiana and was the executive director of hoosiers for economic growth. what is that? guest: it is a combination that is essentially very involved in the education reforms of the last four years, a counterbalance to the state teachers union. under the governor leadership -- governor's leadership, we have some of the most aggressive education reform policies in

the country. it was a great program, a great experience and an opportunity to build on my prior experience as a state legislator. host: louisiana. democrat on the line. byron. caller: i realized the congressman is young, but instead of disparaging the president's inaugural address, i would suggest he reads ronald reagan's inaugural address. plus, if he would read something besides "the wall street journal" or watch fox news, he would have a different perspective. guest: i do read things other than "the wall street journal" and watch things other than fox news. there is this question about

whether president obama is trying to push forward a different vision of america, and i happen to agree with ronald reagan's vision more. he called us to larger challenges than barack obama and i do not want to dissect the entire inaugural address, my biggest criticism would be that rather than calling us all -- as john kennedy said, ask not what your country can do for you, but what you can do for your country, president obama asked us to solve problems through government intervention. i do not think that is the answer. while we were sent here to push our philosophy forward, we were also sent here to work together, and i am proud that i have reached out to at least one of

the democratic class presidents, and we are working across the aisle to put together a host of bipartisan events in the freshman class. between the 47 democratic congressmen, and 35 republicans, we have 92 new folks, and when you combine that with the class of two years ago, more than one third of the chamber has been here for less than a couple of years. there is partisan gridlock in washington. the public is tired of it, and part of it is because people do not know each other. it is harder to demonize people that you know. we have a couple of aunts together, we will doing bowling -- of events together, and we will doing bowling event next month. host: let's look at the number of freshmen in the house. 83 in total sworn in this month, 48 democrats, 35 republicans.

martin, st. james, florida, hi, martin herod -- martin. caller: thanks for taking the call. mayor bloomberg has petitioned the federal government to pay for his police force while they operated during hurricane sandy. he turned down the national guard. in nassau county, the national guard took control, and my mother who lived there and had been wiped out, was safe. in rockaway beach, where my daughter lives and was wiped out, they put up signs, you loot, we shoot. it was a very bad thing the mayor did. i think he did it on purpose with disaster capitalism. that is how the government works, and he should have been jailed, actually, for porting those generators, but i digress.

you are a congressman. stopped at $72 million. let him take his police force and take the summer off and go to rockaway beach and enjoy the sand. guest: first, i need to apologize as i saw your math, it was 83 and i said something in the 90's for new congressman. the caller expresses frustration in the challenges over hurricane sandy, and i think the debate has been mischaracterized by some. i voted against the final version of the sandy bill that came out of the house, not because i do not believe there should be federal aid by those struck by the tragedy, but in the current climate if we are

going to provide that aid to an extraordinary event like a hurricane, we have to offset the expense elsewhere. as far as the nuances, or the specifics of the governing challenges of mayor bloomberg, frankly i am not aware of the details the caller is referencing. host: yesterday, a bipartisan group of senators unveiled a framework of innovation -- immigration reform. let's listen to senator menendez talking about the motivation for the legislation. [video clip] >> lastly, as someone who is an advocate of making sure that our economy is strong as a result of immigration reform, and also that we preserve a core value of family unification. how do we do that in a way that is smart and promotes illegal immigration as opposed to having families divided for so long and then pressures on to make choices on becoming reunified. i believe we can take care of all of those issues. host: is that a good reason to

push legislation forward? guest: i like that better than the political reason. some have cited we need immigration reform because republicans have not won elections but i do not think we should set our public policy on immigration on challenges we might have elect orally. the -- electoraly. we should set our agenda on what is the most fair way to deal with the challenges, as currently the system is broken. it is not working for anybody. it is not working in the urban immunities, and certainly not in the counties that i represent in eastern indiana. we need to keep clear governing vegetables in mind. it starts with border -- principles in mind. it starts with border security. it is difficult to have a conversation without the

american people understanding that for national security reasons and reasons of fairness, that the border is secure. we can not have blanket leadership for folks that came here illegally and certainly not given preference over people that have been complying with the rules. that said, i do see immigration reform is one of the areas where there is opportunity for bipartisan consensus to emerge and i am optimistic to see both in the cretin republicans talking about this issue -- both democrats and republicans talking about this issue. host: based on what you have heard, would you sign off? guest: i would reserve signing off until i see the legislation, but a program that starts with securing our border and recognizes we cannot give

like it citizenship to people that have been breaking the rules and have been undocumented in the time they have been here is an important start to the process. i have followed a lot of what marco rubio has had to say, and his argument that the current process results in a de facto amnesty because the current folks are here without penalty and not sent home is a persuasive argument and we need a system that works for everybody. host: here is an e-mail from tom -- i keep hearing that there are 11 million illegals in the us, but that number has stayed, -- has remained constant. before he make a decision, should we not get an accurate count of not just those hispanic speaking, but from asian countries, european countries and those around the globe? guest: that is the challenge, and the e-mail makes an important point. what we can do is what was done

in the 1980 costs, where they did give blanket amnesty, and there was supposed to be undocumented worker program and border security and those things did not happen. it is the beginning of the process, but it has to start with border security and the recognition that we cannot give blanket citizenship to folks that have been breaking the rules third host: representative luke messer, representing the six district of indiana and republican first class resident. neil, republican line. connected it. hi, neil. caller: i think the senators should continue with their pay -- without pay, as those guys make a fortune. host: ok. caller: what they should do is

not allowed bills to be passed until the balanced budget is none. gun-control and immigration are hot items and they are using those to smokescreen the balanced budget so people take their minds off of the balanced budget, but if you are not allowed to have any bills made during that time, then they would be able to get something done quicker, i think. the senate does not care if they do not get paid for a a while, because they will get it in retro anyway. host: ok, no bill, no pay. guest: the caller makes a good point. within a few hours of the house passing the bill, patty murray announced they would pass a budget for the first time in four years out of the u.s. senate. most people recognize that if you do not do your job, you should not get paid. that should apply to congress as well. we will most certainly pass a budget out of the house of representatives and chairman

ryan has made that commitment. the caller makes another point that in our nation's current public policy debate, the elephant in the room, the moose on the table, is our national debt. it is difficult to talk about other topics until this nation stop spending money it does not have been starts the path toward economic recovery that would come if we have a balanced budget. as a matter of priorities, i agree that the balanced budget should come first and i support a balanced budget amendment to our us constitution. it works for state governments, and i think it would work in the federal government, but i did support the no budget, no pay bill. host: representative mcmorris rodgers, ted on a government shutdown.

host: representative mcmorris rodgers is the chairwoman. what do you think about that? guest: she is highlighting that republicans have conviction that we as a nation do not -- have to stop spending money that we do not have. we cannot continue to pile debt on future generations. host: how much is that a threat as opposed to a reality -- are you willing to go that far? guest: we are sitting in the quiet before the storm is the sequester comes due and the continuing resolution. the sequester is part of the law and it means we will spend less money this year. the president has the discretion to exercise what things he pays for and does not

pay for as the budget is reduced. the continuing resolution is another matter, and we could well be where we were in the 1990's if we cannot reach a continuing resolution compromise that both sides can agree to. i think kathy is right. republicans mean business and the president will have to come to the table and work with us or we could see some fireworks. host: bill, hyattsville, maryland, a democrat. hi, bill. caller: can you hear me? host: we sure can. caller: i would like to know from the congressman what exactly is he willing to cut from his district specifically in order to reduce the budget and spending.

i keep hearing from republicans about this cutting spending, but nobody is talking about specifics. is he willing to cut and tell the public, the american people, something he is willing to sacrifice from his district? what is he specifically talking about cutting from his district? host: ok. guest: i have made clear to our district that we are past the point of sacred cows in this process. we need to look everywhere. secondly, in the $1.2 trillion sequester that will come through in the next few weeks, that includes a 10% cut from my own congressional budget, which will amount to a staff person or two that we are not able to hire because of the sequester, and third, i have made very clear that in the current economic climate, i do not support earmarks and i do not

believe we should have earmarks directed at my district or any other districts for that matter. it is not the kind of thing we can afford in the current economic market. in the future, we will have to look at some sort of capital projects process where we are able to have transparency for those kinds of projects, but certainly now i oppose any earmarks, including those to my district. host: congressman messer is our guest, and he is serving as the freshman public in class president. milton, florida. linda is a republican. caller: i feel like the republicans are taking a backseat. they are letting the democrats just do whatever -- they are rewriting the laws. in florida, our votes did not even count.

on the immigration, i feel that they are here illegally and the government is giving them medical care and, then, jobs. i just do not think that is right for the american people, that we are taking back seats, and we are republicans, and they are letting democrats do whatever to rewrite the laws and the constitution. i do not think that is right and i think it is time that the republicans and the americans stand up and stop letting the democrats do what they think is right, and i do not think it is right. host: ok. guest: the caller referenced several things we talked about earlier in this program. one of the point is we will see in the coming six, eight weeks, a conversation about the

direction we need to go and i think you will see republicans stand strong. immigration reform is an important topic, as the caller referenced. there are clear principles -- secure borders, and we can not have blanket citizenship for folks that have been here in violation of the rules and the laws come in any program that passes must comply with those principles at a minimum. i think the caller points out a frustration many of us have. i voted for mitt romney for president, and i believe republican leadership is the way we ought to get it, but there was an election and we have to figure out how to work with a democratically controlled senate and president obama going forward. we do not have two more years to waste as a country, and the balance we are trying to find is a way to stand strong on our principles and figure out a way

to move our country forward. host: illinois. phyllis, independent caller. caller: good morning. what i would like to discuss is they are complaining about spending, but the spending has to do with the fact that we do not have good jobs here. minimum wage jobs is what is going on, so they will not collect taxes that supports our country. number two, two, take something like walmart that has two factories in china, and they ship back a boombox that cost $250, the total cost is $82 to them. the same with general motors. the pickup truck, they sell it for $17,800. the total cost to them is $7,200.

there is no tax on the difference going into our income tax for congress to support us. they are all about free trade, and they should end the war that is costing us over $1 trillion a year. and the war, ring the troops home and use the -- and the war, bring the troops home, and build ships that protect our country. host: let go to congressman messer for a response. guest: the number one point that i would take from all of that is that she is right. the key to getting the country moving again is a growing economy. we have a debate about which philosophy will do the best job moving the country forward. the president has called for higher taxes. we not only had them midnight legislation that raised income

taxes, but you also had payroll tax increases on virtually every american, and the health care package has tax increases in it as well. we will not get further revenue from additional tax increases. the best way to get further revenue is to have more workers, more jobs, which gives you more taxpayers, and that is the republican vision that we will work toward to get that done. host: georgia. go ahead, caller. caller: good morning. it bothers me regarding immigration that senator menendez is on the bipartisan group of eight but he tried to cover up that he hired a staffer that was not only illegal, but also had a criminal history. we'll he be sanctioned, or at least -- will he be sanctioned, or at least is that not hypocritical? guest: i would have to learn

more about the allegations. i am not familiar with them. those charges are meaningful and serious, but it is hard to comment without more information. host: we find this news story from cbs, from december, senator menendez's intern was arrested, and he employed an illegal immigrant that was once a sex offender who is now under arrest. the office is not being held responsible for that. immigration and customs enforcement was initially not responding for comments aired -- comments. this tweet wants to know if you took the grover norquist pledge. guest: i did sign the pledge to not raise taxes. i believe the key to getting america turned around is a

growing economy and the best way to get revenue is to have more jobs, more taxpayers and tax revenue that comes from that. i do not think the solution is to raise more taxes, so i signed the pledge gladly. host: when we have you back here in a year or two years, what will be your strongest recollection to your start in congress? guest: we are on the cusp of a big debate about spending and we will be talking about a debate in one year where we have started to bend the cost curve and started to spend less. it might be a small victory, what a remarkable achievement if we spend less money this year than we did the year before. that does not happen often in washington. i am not so hopeful that this partisan effort with the democratic -- i am also hopeful this bipartisan effort with the

democratic leadership blossoms into something well. i believe you can stand strong on principles but also have civility and i think we can do a little bit to improve the environment. host: sasha on twitter is advocating for more specifics when you talk about earmarks for your district. is it hard as an incoming freshman to take the lumps of what it means to cut spending for your constituents? guest: cutting my own budget by 10% is a significant reduction, and beyond that we have reached a point as a nation where there will be no sacred cows. the pledge we made as a house republican team is that our budget will balance in 10 years and now paul ryan budget of just last year had a lot of praise, and rightfully so because it was the only show in town, but it balance in about 20 years. that is a remarkable difference.

you will see means testing of social security and medicare, probably benefit reductions that would apply to folks closer to 60 in age and a specific plan of proposals that we will roll out in the budget committee over the next couple of months. listen, we are not quick -- kidding. we have to stop spending meet -- money we do not have as a nation. host: congressman luke messer, indiana's sixth strict. thank you for joining us here and welcome back. >> had the u.s. house gavels in for a brief pro forma session. no legislative business, but when they return next week, there are some new faces. republican and the bar challenged then shalt -- and

chandler in kentucky. he ran in 2012 and one. a navy veteran defeated an incumbent republican and went on to win the general election. the first openly bisexual representative of congress and steve horse for was elected, formerly the leader of the nv said it. speaking of nevada, president obama is in las vegas this afternoon. he will be talking about immigration. the president will be live at 2:55 eastern here on c-span. taking us up to 1:00 eastern, we will hear about immigration from "washington journal" viewers. the day, democratic line, virginia. hello. caller: thank you for taking my call.

i am very happy about the agreement, that is important. i also think that all the immigrants that we brought into this country for their cheap labor, we are certainly reaping what we so and we should give them citizenship. certainly the corporations have enjoyed them for the past 30 years. but what i am against is worker programs. right now we have unemployed americans. i know we keep hearing that they are doing jobs that americans will not do, but they are not. they are not willing to work for a wage so low that they cannot possibly raise their family or have a livable wage to even pay for insurance. this is my thing, forget the guest worker program until we employ the americans who are here already. this guest worker program is

exactly how we got here on. that is why we have 11 million undocumented workers and all we're doing is giving in to corporations wanting cheap labor. it is time to stop that. everything else on board, but we have to stop that. host: miriam mentioned the dream act. how will young people be dealt with under this bipartisan proposal? this is from yesterday. [video clip] >> it has been 12 years since i introduced the dream act. we never give up, when you need these young people, you cannot give up. but there were a lot of tears shed in the past. this time around, these young people, after the vote failed on the floor, i said i never give up on you, do not give up on us. that is what this is about.

the dream act will be difficult part of comprehensive immigration reform, giving people the chance they have been dreaming of, pleading for. these people have shown an extraordinary amount of courage, standing up and self identifying to the world who they were. when it came out, this issue started moving to a place where in the last presidential campaign, both candidates were asked their position on the dream act. i think it has been an integral part in bringing us to this moment in time and i would call this happy news for those dreamers. host: that was senator dick durbin, speaking yesterday about the dreamers, the nickname given to young adults who would be affected by the dream act. today pointing out that those who enter the u.s. as children and illegal immigrants, to work in agriculture, they would have

a different path to citizenship. details have not been finalized. there are other provisions dealing with young people. a tweet comes to us from j. kirk -- host: here is the headline from "the arizona republic," this morning. "our immigration system is broken." governor jan brewer, republican of arizona, responded to this proposal yesterday by saying "our nation cannot afford to repeat the mistakes of the past. specifically "

host: james is up next in manassas, virginia. republican, hello, james. caller: thank you for taking my call. i am glad to see that this issue is finally being taken up. there are large numbers of illegal immigrants already here. if we come up with a solution that actually deals with both issues without irritating the people who are here, i think that is the main thing a lot of people looking for. looking to the people who really need it, being in a better place, we like to see the rules followed to get here. in terms of trying to get everyone in and satisfy both sides, it is good to see the

government trying to find a positive answer. host: this is from twitter -- host: mike, what do you think? new haven, ohio. independent line. caller: i am outraged. we have to take care of ourselves before we take care of other people coming into our country. we have already allowed 1 million people to come here legally. we refuse to enact the laws on the books because of corporate america. our elected officials have allowed the pimps to run the show. can anyone say libor ringing? they cannot even police themselves. where the hell is the ethics committee that? host: a bipartisan plan faces

resistance in the gop, that is the headline from "the new york times" today. the story that michael scherer talked about, skeptics in places like south carolina, it says in that story that republicans are betting on opposition from tea party activists, that the most conservative report -- most conservative supporters will continue to take a hard line on immigrants. the senators on monday released this blueprint for immigration policy one day ahead of the president's speech. evidence that the town and immigration may be changing, according to "the new york times." host: we will hear more about

dissension from this plan coming out. first, liz, texas, democrat. hello. caller: i had a couple of brief points to make. i am an educator, teaching english as a second language to students. i had a couple of comments, i hope i have time to make them. i noticed that several families will live in one house because they work for such low let -- such low wages, they cannot get by better than anyone else who is working for $5, and at $7 per hour. when you make that little money, you generally do not pay taxes. in most states you do not have to pay any at all. the other point i want to make, if they're going to be here to work, they need to be paid the same as us, or let us do the

jobs for a decent wage. we used to do that as kids, work on the farms for summer jobs. the other thing is gang members that are not documented, would they be deported and may be labeled domestic terrorists? that is basically what they are , domestic terrorists. i really like the dream act, but i am concerned about the in- state tuition question. i have to pay lots of money to go to school and out of state. i am concerned about if there are going to be, or if they are including in state tuition on this and what the impact will be on our education system. lots of these people need to be taught english and not everyone is qualified to do this. there are a lot of questions here, but overall i am for the dream act. host: one answer to a question that you raised, this is from "usa today."

the proposed pact includes this -- "a process for deportation." we mentioned descend from republicans about this proposal. this is from lamar smith, a senior member of the judiciary committee. host: benton, grand junction, colorado. caller: i lived overseas in saudi arabia and saw the importation of labour into that country from tree tonka, other places. the demand for that unskilled labor, such a that the documented saudi arabia, it gave me a perspective about what is happening to the united states. i had been on the fence on how to deal with that.

it made the practical reality for the need for unskilled workers in these advanced countries to do certain things, like what we saw happening in the united states -- i see this legislation as a pragmatic step toward making it a more manageable situation such that everyone benefits. i think that the hurdles, if you will, about citizenship and how they get there are reasonable, given that the united states is a highly desirable place for people to have a citizenship. i think it is a very progressive move. the fact that we are all immigrants, we need to be able to identify with the conditions with which these immigrants are coming to our country, we need to embrace that. i think that the law proposed in the senate is something that would truly do that, carrying on the great tradition that we the great tradition that we have that is